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UNIFIED PROGRAM CONSOLEDATED FORM TANKS UNDERGROUND STORAGE Ti k-NKS - TANK PAGE 2 V1.PIPING CONSTRUCTION Check all th t 2pp1y) -Lag.9 of I UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1,PRESSURE El 2.SUCTION ❑3.GRAVITY 458 PRESSURE [12. SUCTION 0 3,GRAVITY 459 CONSTRUCTION SINGLE WALL J--]3.LINED TRENCH E]99,OTHER 460 El SINGLE WALL D 95.UNKNOWN 462 MANUFACTURER Z 2.DOUBLE WALL El 95,UNKNOWN [I DOUBLE WALL ❑99.OTHER MANUFACTURER Smith Fiberglass 461 MANUFACTURER 463 ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE w/100% METHANOL ❑1.BARE STEEL [j 6.FRP COMPATIBLE W1100%MFTHANOL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL 0 Unknown ❑2. STAINLESS STEEL [3 7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE W1 CON-TENTS C1 99. Other ❑3. PLASTIC COM?ATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) 0 99. OTHER 4.FIBERGLASS El B.FLEXIBLE(HDPE) ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5,STEEL W/COATING [19.CATHODIC PROTECTION 464 C1 5. STEEL W/COA rING ❑95.UNKNOWN 465 VII.PIPING LEAK DETECTION(Check all that apply)(A description ortie monitoring proV-am shall be submitted to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESS UT IZED PIPING(Check all that apply): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST]6aT_H AUTO PUMP OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS, ❑2.MONTHLY 0.2 GPH TEST ❑2. MClNTHLY0.2GPH TEST Ll 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑3.AN4UAL INTEGRITY TEST(0-IGPM ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS COONAL SUCTION SYSTEMS(Check all that apply) ❑S.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPM SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): [3 6. TR IENNIAL INTEGRITY TEST(0.1 GPM [-17.SELF MONITORING SAFE SU MON SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW El 7, SE'-F MONITORING- ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): D 8. DAILY VISUAL MONITORING 0 9. BD iNNIAL INTEGRITY TEST(0.1 GPM SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESS ED PIPING(Check all that apply): l0. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) AL�RMS AND(Cheek one) El a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS []a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM El b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION [1c'' NO AUTO PUMP SHUT OFF [3c NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR(3-0 GPH TEST)WIT FLOW SHUT [3 11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION 12. ANNUAL INTEGRITY TEST(0.1 GPM 0 12. ANNUAL INTEGRITY TEST(0.1 GPM SUCTIONIGRAVIT'Y SYSTEM SUC710NIGRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHO AUTO PUMP SHUT OFF [j 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW jj 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.1 GPM [1 16.ANNUAL INTEGRITY TEST(0.1 GPM 017. DAILY VISUAL CHECK [3 17. 1-AILY VISUAL CHECK VIII.DISPENSER CONT A[NMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [3 4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AN VISUAL ALARMS ❑5.TRENCH LINER I MONITORING ®3 CONTINUOUS DISPENSER SENSOR WITH AUTOS OFF FOR ❑6.NONE 469 2003 DIES AUDIBLE AND VISUAL ALARMS M OWNER/OPERATOR SIGNATURE I testify that the information provided herein is true and accurate w the best of Trrf knowledge. SIGN 7RF OF 0 R/. AT DATE 470 472 471 TITLE OF( ERIOPERATOR NAM) V�0WNEPJOPR%ATORjprfilt) ,Q�) 0 ERATOR jo(�r M_ Fermi;Number(For local use Only) 473 Permit Approved(For local use only) 474 Permit Expiration Date(For local use only) UPCF(12199 revised) 12 Formerly SWRCB Form B